Classifying Medication Use in Clinical Research

Background: Medication use data are usually collected in clinical research. Yet no standardized method for categorizing these exists, either for sample description or for the study of medication use as a variable. Objective: The present investigation was designed to develop a simple, empirically based classification scheme for medication use categorization. Method: The authors used factor analysis to reduce the number of possible medication groupings. This permitted a pattern of medication usage to emerge that appeared to characterize specific clinical constellations. To illustrate the technique’s potential, the authors applied this classification system to samples where sleep disorders are prominent: chronic fatigue syndrome and sleep apnea. Results: The authors’ classification approach resulted in 5 factors that appear to cohere in a logical fashion. These were labeled Cardiovascular or Metabolic Syndrome Medication, Symptom Relief Medication, Psychotropic Medication, Preventative Medication, and Hormonal Medication. Conclusions: The findings show that medication profile varies according to clinical sample. The medication profile for participants with sleep apnea reflects known comorbid conditions; the medication profile associated with chronic fatigue syndrome appears to reflect the common perception of this condition as a psychogenic disorder.

Impaired sleep in chronic fatigue syndrome: how is it best measured?

The goal was to examine comparative efficacy of polysomnography, actigraphy, and self-report in evaluating the sleep/wake experience of individuals with chronic fatigue syndrome (CFS). Sleep parameters were evaluated by the three measurement modalities for the same night in 49 participants with CFS. Psychological and daytime functioning were measured by self-report. Results indicate that: (a) objectively measured nocturnal sleep time effectively approximated subjective experience although nocturnal wakefulness did not; (b) total sleep time and sleep efficiency differentiated individuals with and without insomnia complaints; (c) daytime sleepiness, fatigue, and non-refreshing sleep were not reflected by the objective sleep-related measures (polysomnography and actigraphy).

Acute respiratory distress following fine needle aspiration of thyroid nodule: case report and review of the literature

BACKGROUND

Fine needle aspiration (FNA) is a widely used practice to assess thyroid lesions, with a low morbidity rate. Although neck hematomas following this procedure are quite common, only three cases of massive hemorrhage causing acute airways obstruction have been previously described.

CASE REPORT

We report the case of a 74 years old female with acute respiratory distress following ultrasound-guided FNA for a right paraisthmic thyroid nodule. The patient was admitted to the Emergency Room (ER) 6 hours after the procedure with a large neck hematoma compressing the cervical trachea and requiring surgical decompression. Patient underwent endotracheal intubation followed by isthmectomy and evacuation of the hematoma. Extubation was made 24 hours later in the Intensive Care Unit and the patient was discharged after 48 hours uneventfully.

CONCLUSIONS

Acute thyroid hemorrhage following FNA is very rare but still possible. Prompt intervention is mandatory for patients with rapidly evolving symptoms.

Sleep apnea and psychological functioning in chronic fatigue syndrome

Objectives were to explore: (1) whether sleep apnea/hypopnea syndrome (SAHS) should be considered a chronic fatigue syndrome (CFS) comorbidity, rather than a diagnostic exclusion criterion; and (2) to compare sleep/wake/ psychopathology in individuals with CFS, controls and another illness. Participants (CFS, SAHS, controls) completed questionnaires and were evaluated for SAHS; 68 percent were subsequently diagnosed with SAHS. CFS participants with and without SAHS did not differ. Both clinical groups were less well adjusted than controls. We conclude that SAHS should not be an exclusion criterion for CFS and that psychological problems in CFS seem a consequence of coping with illness.

Sleep disorder symptoms are common and unspoken in Canadian general practice

OBJECTIVE

Primary care patients were surveyed for what sleep disorder symptoms they discussed with their physicians. Their responses were compared with those of new Sleep clinic patients. The goal was to discover what symptom presentation leads to a successful referral to a sleep clinic.

METHODS

We recruited two samples: 191 older Primary care patients and 138 Sleep clinic patients. Participants completed the Sleep Symptom Checklist (SSC). This consists of 21 symptoms in four domains: insomnia, sleep disorder, daytime symptoms and psychological distress. All respondents indicated which symptoms had been discussed with their physician in the past year. Primary care subjects were designated as Decliners (completed SSC, refused further evaluation), Dropouts [completed some evaluation steps, but not polysomnography (PSG)] and Completers (completed PSG).

RESULTS

Primary care participants frequently had symptoms but relatively few had discussed them with their doctor. Sleep clinic participants discussed significantly more symptoms with their referring physician than did Primary care Dropouts or Decliners in all categories except psychological distress. Primary care Completers, 88.5% of whom were ultimately diagnosed with sleep apnoea/hypopnoea syndrome and/or periodic limb movement disorder, also discussed their sleep disorder symptoms less frequently than did Sleep clinic patients but tended to give more prominence to symptoms of insomnia and impaired daytime function.

CONCLUSIONS

The findings suggest that Primary care patients often have symptoms they do not discuss, even when a primary sleep disorder exists. The brief SSC checklist, developed in our laboratory, has potential to improve the referral rates of older primary care patients who have sleep disorder.

A diagnostic symptom profile for sleep disorder in primary care patients

OBJECTIVE

The aim of the present study was (1) to evaluate the extent and nature of sleep disorder-related symptoms in the older primary care patient population and (2) to differentiate a pattern of self-reported symptoms that identify patients who should be referred to the sleep clinic for further evaluation.

METHOD

One hundred ninety-six older adults recruited from family practice centers were administered a brief symptom survey measure. All were invited to participate in an extensive self-report evaluation, consultation with a sleep medicine specialist, and an overnight polysomnographic study.

RESULTS

A substantial number of older primary care patients report symptoms related directly or indirectly to physiological sleep disorder. Over 30% of total reported some insomnia, 40% daytime sleepiness, and 10% apnea. Those participants who agreed to pursue further aspects of the study protocol endorsed a higher number and greater severity of primary sleep disorder symptoms than those who declined to continue beyond the first phases. Participants who chose to pursue polysomnography (13% of total) had a very high rate (88.5) of diagnosed sleep disorder.

CONCLUSION

This study suggests that an older patient, male or female, who both endorses medically unexplained daytime sleepiness, fatigue, or other sleep disorder related symptoms and agrees to further evaluation, including overnight polysomnography, is at substantial risk for physiologically based sleep disorder. In the future, a brief, validated measure, such as the Sleep Symptom Checklist used in this study, would be an important part of the diagnostic process.

A large population of galaxies 9 to 12 billion years back in the history of the Universe

To understand the evolution of galaxies, we need to know as accurately as possible how many galaxies were present in the Universe at different epochs. Galaxies in the young Universe have hitherto mainly been identified using their expected optical colours, but this leaves open the possibility that a significant population remains undetected because their colours are the result of a complex mix of stars, gas, dust or active galactic nuclei. Here we report the results of a flux-limited I-band survey of galaxies at look-back times of 9 to 12 billion years. We find 970 galaxies with spectroscopic redshifts between 1.4 and 5. This population is 1.6 to 6.2 times larger than previous estimates, with the difference increasing towards brighter magnitudes. Strong ultraviolet continua (in the rest frame of the galaxies) indicate vigorous star formation rates of more than 10-100 solar masses per year. As a consequence, the cosmic star formation rate representing the volume-averaged production of stars is higher than previously measured at redshifts of 3 to 4.

Matriz óssea homóloga desmineralizada associada à medula óssea autógena fresca na artrodese vertebral dorsolateral lombar em coelhos

Foi avaliada a matriz óssea homóloga desmineralizada (MOD), associada à medula óssea autógena fresca (MO), na artrodese vertebral dorsolateral lombar em 24 coelhos (grupo 1), depositada sobre os processos transversos de L5-L6 previamente descorticados. Em outros nove coelhos (grupo-controle), foi realizada apenas a descorticação dos processos transversos e nas diferentes avaliações, foi observada insignificante reação periosteal local, sem união óssea. No grupo 1, às cinco semanas de pós-operatório, 87,5% dos animais apresentaram união (artrodese) à palpação, seguido por 75 e 100% às sete e nove semanas, respectivamente. Os índices de artrodese aos RX foram de 50%, 62% e 75%, no mesmo período de avaliação. Histologicamente, às cinco semanas havia características de osteointegração da MOD com os processos transversos descorticados, de onde partiram os vasos sangüíneos que penetraram a matriz, e presença de ilhas de cartilagem no centro do enxerto. Nas semanas seguintes, a ossificação endocondral evoluiu e a MOD foi quase totalmente substituída por tecido ósseo trabecular, formando uma ponte de osso maduro entre e sobre os processos transversos adjacentes, propiciando ao segmento operado maior resistência mecânica em comparação aos segmentos adjacentes. A associação da MOD com a MO mostrou-se uma opção exeqüível e de baixo custo na artrodese vertebral dorsolateral lombar em coelhos.

Study of hardness and roughness modification in explanted joint components

The significant wear of the UHMWPE bearings of explanted knee prostheses is produced mainly by micrometric debris ("third-body" wear) that diffuse toward the mobile metal-polymer interface. Here debris is crushed during the movement producing scratches in the metal and in the polymeric surfaces. Mechanical stress and the biological effects change the physical polymeric properties. In order to evaluate the area of UHMWE bearings submitted to high load stresses, in this work physical investigations are performed on the explanted knee prosthesis. Particularly, the roughness profile analysis (RPA) and the micro-hardness measurements (MHM) resulted suitable for the localisation of the mechanical and biological wear area. In the stressed zone, surface treatments could be applied in order to improve the mechanical resistance of the polymeric material. Particularly, the ion implantation with heavy ions is proposed to enhance the polymeric wear resistance. The Scanning Electron Microscopy (SEM), Energy Dispersive X-ray Spectrometry (EDX) and Infrared absorption spectroscopy (FTIR) techniques were also applied and results discussed.

Analysis of risk factors for the development of GVHD after T cell-depleted allogeneic BMT: effect of HLA disparity, ABO incompatibility, and method of T-cell depletion

Multivariate analysis was performed to determine the independent factors affecting the risk of acute GVHD (aGVHD) grades II to IV and extensive chronic GVHD (cGVHD) and the rate of survival in 481 recipients of T cell-depleted (TCD) marrow allografts who received transplants at a single center between 1991 and 2000. All patients received grafts partially depleted of CD3+ T cells by complement-mediated lysis using 2 narrow-specificity monoclonal antibodies (MoAbs), T10B9.1A-31 (n = 400) or Muromonab-Orthoclone OKT3 (n = 81). Factors considered in the analysis included patient/donor sex, age, cytomegalovirus (CMV) status, and ABO blood group along with T-cell dose, disease, and disease status, donor relationship, HLA antigen (Ag)mismatch (MM), growth-factor use, anti-thymocyte globulin use, year of transplantation, and the MoAb used for TCD. The results showed an association of HLA with an increased relative risk (RR) of aGVHD for recipients of grafts from relateddonors that were > or =2 Ag MM (n = 73, RR = 2.09, P = .005), matched unrelated (UR) donors (n = 130, RR = 1.98, P = .004), and > or =2 Ag MM UR donors (n = 34, RR = 2.68, P = .003) compared with the baseline matched-sibling group (n = 121). No increased risk of aGVHD was seen for 0 to 1 Ag MM family donors (n = 24) or 1 Ag MM UR donors (n = 99). aGVHD risk was increased with minor, but not major or major-minor, ABO disparity (RR = 2.0, P = .003) compared with that of ABO-identical pairs. We found less effective TCD and resultant higher T-cell dose for recipients of grafts that were T cell depleted using OKT3. However, the use of OKT3 and not the T-cell dose was associated with increased aGVH-D risk (RR of 1.84, P = .001). Increased risk of extensive cGVHD was associated with patient age of >20 years (RR = 2.2, P < .0001) and with CMV status (positive patient/negative donor, RR = 1.9, P = .002). Decreased survival was associated with older age (>20 years), a > or =2 Ag MM related donor, a 1 or > or =2 Ag MM UR donor, risk group, and a CMV-positive patient/-negative donor pair. There was no difference in survival for 0 to 1 Ag MM related or matched UR donors compared with the baseline group. These data indicate that there are quantitative as well as potential qualitative differences in outcome depending on the TCD method. Expected and unexpected risk factors for GVHD and survival were associated with partial TCD. Our data support the consideration of ABO match in donor selection, the preferential selection of CMV-positive donors for CMV-positive recipients, and the acceptance of 1 but not > or =2 Ag HLA MM donors.

Novel use of bovine zeta-crystallin as a conformational DNA probe to characterize a phase transition zone and terminally differentiating fiber cells in the adult canine ocular lens

Using a novel immunocytochemical staining method, we aimed to characterize the phase transition zone (PTZ) (approximatly 100 microm) in adult ocular lenses and the process of terminal differentiation (denucleation) within normal fiber cells. The binding to DNA of zeta-(zeta) crystallin (Z-DNA-binding protein) and anti-double-stranded (ds-)-B-DNA antibody probes was found to decline gradually throughout denucleating fibers, with a precipitous decrease occurring at about 100 microm (PTZ). Nuclei of superficial fiber cells (in front of the PTZ) showed the highest DNA probe-binding values, followed by middle fibers (MF) and deep fibers (DF). With the use of zeta-crystallin, anti-ds-B-DNA antibody, and anti-single stranded (ss-) DNA antibody probes, it was possible to reveal a loss of reactivity of fiber cell ds-DNA. Ss-DNA antibody binding was seen initially in the MF and reached its highest intensity level in the DF. The pattern of zeta-crystallin probe-DNA reactivity correlates with the loss of anti-B-DNA antibody staining and decreased eosin-protein staining. These data suggest that a reorganization of DNA and intracellular protein supramolecular order in normal adult lenses occurs at a depth of about 100 microm (PTZ).

[Peristomal laparocele: particular indications for the use of prosthetic materials]

The authors report the case of a female patient suffering from colic neoplasm and a vast peristomal laparocele, the long-term outcome of a rectal amputation that the patient underwent at a young age. After colic resection, a vast area of surgical mesh in dacron was modelled and positioned in a retromuscular scat, thus allowing the hernia pathology to be resolved relatively simply, owing to its particular location-in correspondence with a preternatural anus-until not long ago this would have represented an absolute contraindication to the use of prosthetic materials. A precise surgical approach, marked by a scrupulous respect for aseptic conditions, is essential in these circumstances owing to the persistent risk of septic complications.

Electroporation of antibodies, DNA, and other macromolecules into cells: a highly efficient method

While antibodies are a major extracellular tool of the highest specificity to answer important biomedical questions, the improvements in electroporation discussed below may make it feasible to also use antibodies as an intracellular deletion tool to study (a) viruses inside the cell, (b) cancer cells, (c) signal transduction, (d) genetics, (e) metabolism, and (f) other structures and mechanisms. Already, others have succeeded in depositing macromolecules, including antibodies (Abs), and nucleic acids inside cells, using many techniques, including electroporation (EP). However, EP has limitations that have precluded its widespread use, particularly its high kill rate for cells and the low percentage of cells that are able to incorporate macromolecules. If these limitations could be overcome for Abs and nucleic acids, then it would be practical to use them as highly specific probes for intracellular molecules. In our experiments using EP, we were able to largely prevent lethality for cells during EP by employing a commercially available cold-storage solution for organ transplants containing high K(+) and Mg(++) (ViaSpan, Belzer UW cold-storage solution, DuPont Pharmaceuticals). This solution decreased cell death after standard EP by an average of 50% for a number of cell lines. Viability of WISH cells after EP approached 100%. In transfection studies, ViaSpan medium strongly increased both P3HR1 cell survival as well as the total number of cells transfected with DNA for green fluorescent protein (GFP). In additional experiments with Abs, we were able to strongly increase the percent of cells that incorporated Ab by using two serial EPs. This enhanced the intracellular protection by Abs against viruses in Vero cells from 64% to a maximum of 98%. We were able to further simplify the EP technique by using unpurified antiserum in place of purified IgG. Thus, this EP technique offers multiple advantages: simplicity, high cell viability, high effectiveness, high specificity, rapid action, usefulness with adherent or non-adherent cells, and no requirement for purification of antibodies from antiserum.

The residues between the two transformation effector sites of Epstein-Barr virus latent membrane protein 1 are not critical for B-lymphocyte growth transformation

Epstein-Barr virus (EBV) latent membrane protein 1 (LMP1) is essential for EBV-mediated transformation of primary B lymphocytes. LMP1 spontaneously aggregates in the plasma membrane and enables two transformation effector sites (TES1 and TES2) within the 200-amino-acid cytoplasmic carboxyl terminus to constitutively engage the tumor necrosis factor receptor (TNFR)-associated factors TRAF1, TRAF2, TRAF3, and TRAF5 and the TNFR-associated death domain proteins TRADD and RIP, thereby activating NF-kappaB and c-Jun N-terminal kinase (JNK). To investigate the importance of the 60% of the LMP1 carboxyl terminus that lies between the TES1-TRAF and TES2-TRADD and -RIP binding sites, an EBV recombinant was made that contains a specific deletion of LMP1 codons 232 to 351. Surprisingly, the deletion mutant was similar to wild-type (wt) LMP1 EBV recombinants in its efficiency in transforming primary B lymphocytes into lymphoblastoid cell lines (LCLs). Mutant and wt EBV-transformed LCLs were similarly efficient in long-term outgrowth and in regrowth after endpoint dilution. Mutant and wt LMP1 proteins were also similar in their constitutive association with TRAF1, TRAF2, TRAF3, TRADD, and RIP. Mutant and wt EBV-transformed LCLs were similar in steady-state levels of Bcl2, JNK, and activated JNK proteins. The wt phenotype of recombinants with LMP1 codons 232 to 351 deleted further demarcates TES1 and TES2, underscores their central importance in B-lymphocyte growth transformation, and provides a new perspective on LMP1 sequence variation between TES1 and TES2.

[Sciatic, femoral and cutaneous nerve block for arthroscopic meniscectomy in a patient with Eisenmerger's syndrome. Case report]

The principal complication to prevent in Eisenmerger disease with left-right shunt during surgery decreasing of systemic pressure with reduction of pulmonary perfusion and break-down of central oxigenation. A 32 ys old male patient (ASA risk 3) to undergo an extirpation of meniscus by arthroscopic surgery, suffering from Eisenmerger's syndrome with left-type only ventricle, diagnosed when he was 3 ys old and but no repaired by any operation. We performed a sciatic, femoral and lateral cutaneous of thigh nerves block with ropivacaine, that consents a prolonged antalgic effect in postoperative period with minimizing of systemic and pulmonary hypotension risk compared to general, epidural or spinal anaesthesia. Basing on our experience and literature references we think that the anaesthesiological technique with the lowest risk for lower limb surgery in Eisenmerger's syndrome is truncular block.

[Epidural analgesia for painless delivery. Our experience]

BACKGROUND

We know that a stress condition causes hormonal responses (cortisol, prolactin, TSH, ACTH, catecholamines, beta-endorphines). This hormonal "storm" causes metabolic and haemodynamic changes that can get worse postoperative outcome as well as birth. Analgesia for labour is an anesthesiological procedure which spreading in Italy resulted very difficult, for instance, especially in southern Italy, "old popular believes" (such as paralysis risk after lumbar puncture, Post-Dural Puncture Headache (PDPH) and the confusion between epidural and subdural anesthesia).

METHODS

In front of these problems we report our experience in this field. Experimental plan: in our retrospective study we examined painless labour cases and we compared them with natural labour cases without analgesia.

ENVIRONMENT

women of this study were pregnant admitted in obstetrics department of our hospital at the end of pregnancy.

PATIENTS

pregnant women who wanted epidural analgesia were 50 (group A); data group A were compared with data of 50 pregnant women who refused analgesia (group B).

TECHNIQUE

beginning labour, when cervical dilatation was 3 cm and foetal head was going down we performed epidural puncture and positioned, catheter in epidural space giving opiate and local anesthetic drugs using "top-up" method.

DATA

we compared APGAR-score after birth and the judgement expressed by women of the two groups.

RESULTS AND CONCLUSIONS

APGAR-score in new-borns with epidural analgesia in higher than new-born without epidural analgesia; furthermore, patients who choose painless labour expressed a better judgement than women who refused epidural analgesia.

[The use of prosthesis material in emergency surgery. Comments on a clinical case]

The authors briefly report the case of a patient in whom a double Mersilene graft was used to repair a strangulated umbilical hernia. This report is interesting for various reasons. Firstly, the fact that surgery was performed under emergency conditions and secondly, the position of the graft, which was certainly not ideal--even if obligatory owing to the circumstances under which the operation was performed--in the abdominal wall. In spite of the successful results obtained, the authors feel that graft should preferably be used in elective surgery in which additional operations are not required which may further contaminate the operating field. In particular, special attention should be paid to graft position in relation to the various layers of the abdominal wall.

Therapeutic infiltration of the facet joint in minor intervertebral disease

SUMMARY

A CT-guided infiltration technique of the facet joints was employed on a group of 20 patients suffering from sciatica without any signs ofmorphostructural alteration of the facet joints, secondary to Minor Intervertebral Disease (MID). The typical flouroscopically guided intra-articular facet arthrography has been substituted by a CT-guided technique that privileges therapy rather than diagnosis. The study involved 20 patients between 29 and 57 years of age (average 44.5), of both sexes (16 females and four males). The average time which elapsed from onset of symptomatology was 9.5 months. At seven days after the first treatment subjective results were considered excellent by 11 patients (55%), good by one (5%) and satisfactory by one (5%). Six out of20 patients (30%) failed to gain any relief of symptoms. Only one patient (5%) had a worsening of pain. Clinical evaluation by the physician at the same time showed a good result in 11 patients (55%), satisfactory in two (10%). In six patients (30%) the symptomatology was unchanged. At 4 months the subjective results were excellent in three (15%), good in six (30%) and satisfactory in two (10%) . Nine (45%) had no positive results. The clinical examination was excellent in tWo (10%), good in seven (35%), satisfactory in two (10%) and without any relief of symptomatology in nine (45%). These results encourage the use of CT-guided infiltration that, together with the small amount of contrast medium injected into the joint space, make it a safe technique for patients, avoiding or reducing complications.

[Combined use of real-time digital subtraction radioscopy and computerized tomography: potential advantages in diagnostic and interventional radiology]

The idea of combining fluoroscopy and CT arose from the daily practice in diagnostic and interventional radiology. A Diasonics OEC high-performance image intensifier complete with a digital subtraction system was connected to a Siemens Somatom-DRH CT scanner to work in tandem. CT is used for a localization in-depth and fluoroscopy for the subsequent maneuvers within an organ or body compartment. With this combination, complex procedures such as transarterial portography, percutaneous embolizations, pain treatment and manipulation for catheterization of the bile ducts and urinary tract could be performed in one place and in one session. CTF is especially useful when patients should not be moved about from room to room or undergo an examination in several sessions, as it happens with children or critically ill or contagious patients.

Linkage analyses of extracellular glucans from Streptococcus sanguis and Streptococcus mitior

Similar alpha-(1-->6) linkage-rich, soluble, extracellular glucans have been isolated from six strains of two genetically distinct groups of Streptococcus sanguis and three strains of Streptococcus mitior.